Zimmet Vein & Dermatology :: New Patient Form

Document Sample
Zimmet Vein & Dermatology :: New Patient Form Powered By Docstoc
					                                                                 NEW PATIENT REGISTRATION

                                                                            Today’s Date:

Please complete the following information for our records at Zimmet Vein & Dermatology.

 Last Name:                         First Name:                             Middle Initial:
 Street Address:
 City:                              State:                                  Zip:
 Age:                               Birth Date:                             SS # (optional):
 Driver’s License #:                Expiration Date:
 Home Phone:                        Cell Phone:                             Work Phone:
 Primary Care Physician:            Referred By:
 Gender:     M      F               Marital Status:    Single     Married     Widowed          Divorced
 Employer:
 Spouse’s Name:                       Phone Number:


WOULD YOU LIKE TO JOIN OUR ZNEWS MAILING LIST?                      Yes              No
We’ll keep you up-to-date via email on new treatments, events and specials. Your privacy is important to
you and us. Your information will not be shared with other parties.
                                                 Email Address: ________________________________

ARE YOU CURRENTLY COVERED BY MEDICARE?                               Yes            No

PLEASE COMPLETE THE FOLLOWING IF THE PATIENT IS A MINOR:
 Name of Person Completing Form:      Last Name:                 First Name:
 Relationship to Patient:     Mother  Father     Guardian Other:
 Address (if different from patient):
 Phone Number:

EMERGENCY CONTACT (OTHER THAN HOUSEHOLD MEMBER):
 Last Name:               First Name:                                       Middle Initial:
 Relationship to Patient:                Phone Number:
 Address:
 City:                    State:                                            Zip:

PLEASE READ & SIGN:
I AUTHORIZE STEVEN E. ZIMMET, MD TO RELEASE MEDICAL INFORMATION NECESSARY TO FILE A CLAIM
WITH MY INSURACE COMPANY.

 Signed:                                                     Date:

PAYMENT IS DUE AND PAYABLE AT THE TIME THAT SERVICES ARE RENDERED. I UNDERSTAND I MAY
RECEIVE SEPARATE BILLS FOR CERTAIN SERVICES PROVIDED OUTSIDE THIS OFFICE, SUCH AS
RADIOLOGY OR LABORATORY SERVICES. I CERTIFY THAT THE INFORMATION ABOVE IS CORRECT.

 Signed:                                                     Date:



1500 WEST 34TH STREET • AUSTIN, TX 78703 • o (512) 485-7700
   • f (512) 485-7702 • info@skin-vein.com • www.skin-vein.com
                                             PATIENT HISTORY FORM

Patient Name:                                                              Date:
Date of Birth:


MEDICAL HISTORY
(Check as many as apply)
                           Y    N                                Y     N                            Y   N
Anemia/Blood Disorder                Prosthetic Heart Valve                Are You Pregnant?
Bleeding Problems                    Radiation Treatment                   Are You Breastfeeding?
Cold Sores                           Thyroid Disorder
Defibrillator                        Skin Cancer                           Any Metal Implants?
Diabetes                             Other Cancer                          (Please specify)
Heart Disease                        Other Medical Problems
High Blood Pressure                  (Please specify)
Keloids/Abnormal Scars
Pacemaker
Pigmentation Problems
Poor Wound Healing




CURRENT MEDICATIONS                                 MEDICATION ALLERGIES
(Check as many as apply)                            (Check as many as apply)
                                 Y       N                                             Y     N
Aspirin                                             Lidocaine
Birth Control                                       Novocaine
Blood Thinner                                       Antibiotics
Heart Medication                                    (Please specify)
Hormones
Insulin
High Blood Pressure
                                                    Other
Other Medications                                   (Please specify)
(Please specify)




Is there anything else you feel we should know about your medical history?




HOW DID YOU HEAR ABOUT US?
  Physician Referral: (Please specify)                      Friend Referral:
                                                            Living Social
  Website (www.skin-vein.com)                               Groupon
  Google                                                    Print Ad: (Please specify magazine)
  Yahoo!                                                    Other:
  Citysearch
  YELP

1500 WEST 34TH STREET • AUSTIN, TX 78703 • o (512) 485-7700
   • f (512) 485-7702 • info@skin-vein.com • www.skin-vein.com
                                        SKIN & VEIN CARE NEEDS



To help us provide you with the services you desire and the best treatment possible,
please answer a few questions regarding your skin and vein care needs.


Patient Name: _________________________                              Date: _______________________



YOUR SKIN AND VEIN CARE NEEDS:

Please indicate your concerns about your skin or veins.

  Aging Chest and/or Neck                 Lip Enhancement                  Spider Veins (facial)
  Aging Skin- Face                        Non-invasive Fat Removal         Spider Veins (legs)
  Crows feet                              Pigmentation problems            Sun damage
  Frown lines                             Rosacea                          Wrinkes
  Hair removal                            Saggy/loose skin                 Varicose Veins
  Hand Veins                              Scars
  Hyperhidrosis (Sweating)                Smile lines


Other: _______________________________________________________________



OUR COSMETIC DERMATOLOGY, LASER TREATMENTS, VEIN AND SPA SERVICES:

Please indicate the procedures or treatments you would like additional information about.

      COSMETIC                                                   VEIN                    SPA
  DERMATOLOGY                 LASER TREATMENTS                SERVICES                SERVICES
  Acne/Acne Scarring         Blu-U Light                  Spider Veins             Skin care advice
  Botox                      Facial Veins                 Varicose Veins           Products
  Coolsculpting              FotoFacial Plus              EVLT                     Facials
  Fillers                    Fractional CO2               FoamSclerotherapy        Chemical Peel
  Peels                      Hair Removal                 Phlebectomy              Gentlewaves
  EndyMed Pro                Rosacea                      Sclerotherapy            Microdermabrasion
  Ultherapy                  Liposonix                    Ultrasound testing       Lash & Brow Tinting
  Skin Tightening            Non-Invasive Fat removal



Other: _______________________________________________________________

 1500 WEST 34TH STREET • AUSTIN, TX 78703 • o (512) 485-7700
    • f (512) 485-7702 • info@skin-vein.com • www.skin-vein.com
          Patient Consent for Use of Email Communications

To better serve our patients, Zimmet Vein and Dermatology has established an
email address for some forms of communication. For routine matters that do not
require immediate response, please feel free to contact us at zimmet@skin-
vein.com. This form of communication is not appropriate for use in an emergency.
The turnaround time for routine patient communications is 24 hours.

If you require urgent or immediate attention, this medium is not
appropriate. Please call our office at 512-485-7700 or call 911 if this is an
immediate medical emergency.

When sending email communications, please put the subject of your message in the
subject line so we can process it more efficiently. Also, be sure to put your name,
date of birth and return telephone number in the body of the message. We also ask
that you acknowledge receipt of emails coming from this office by using the auto
reply feature.

Communications relating to diagnosis and treatment will be filed in your
medical record.

This office is dedicated to keeping your medical record information confidential.
Despite our best efforts, due to the nature of email, third parties may have access
to messages. When communicating from work, you should be aware that some
companies consider email corporate property and your messages may be
monitored. Even when emailing from home, you may feel that access to your email
is not well controlled, so you should take that into consideration. In addition, you
should be aware that, although addressed to me, my staff would have access to
this information.

I understand that this office will not be responsible for information loss or delay or
breaches in confidentiality that are due to technical factors beyond this office’s
control.

I understand and agree to the above email policy.

By signing below, you are agreeing that we may send medical related
correspondence to you via email, and that we may respond to your emails to us via
email.


_________________________________                           _________________
Patient’s Signature                                         Date



1500 WEST 34TH STREET • AUSTIN, TX 78703 • o (512) 485-7700
   • f (512) 485-7702 • info@skin-vein.com • www.skin-vein.com

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:36
posted:10/4/2012
language:Latin
pages:4